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I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. your signature. a wet signature is required. print the form and sign. )/Q 0>> endobj 201 0 obj <>stream endstream endobj 202 0 obj <>/DA(/CourierStd 12 Tf 0 g)/F 68/Ff 8388609/FT/Tx/P 1 0 R/StructParent 78/T(Last[0])/TU(DO NOT WRITE BELOW THIS LINE \(FOR SSA USE ONLY\). N P N. D O C. N T I, C Ay N. I T V. P B C. E V I. E V Ay. E V C. P R Ay. N W R. D N R. Unit. Evidence submitted. SIGNATURE AND TITLE OF EMPLOYEE\(S\) REVIEWING EVIDENCE AND/OR CONDUCTING INTERVIEW. Date. D C L. Date. End SSA use Only section. 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